Compliance with national physical health screening programmes in an inpatient rehabilitation setting: a completed audit cycle

Rhian Bradley
Vijay Delaffon

Aims and Methods

A baseline audit of inpatient compliance with national physical health screening programmes was carried out on two inpatient rehabilitation units. A questionnaire was administered to non-compliant patients to identify potential barriers to screening.  Based on the findings interventions were made to the physical health assessment process and its impact on improving compliance with national screening programmes was re-audited.

 

Results

The initial audit revealed that compliance with screening targets was suboptimal in this population. Barriers to accessing screening were identified as predominantly emotional, with issues relating to perceived invasion of personal space, mistrust of screening programmes, fear of pain and previous negative experiences being prominent. Improvements were noted in compliance following implemented interventions.

 

Clinical Implications

People living with severe mental illness have suboptimal use of preventative health strategies. This can be improved by supporting these individuals to access screening. 

Declaration of interest: None

People living with Severe Mental Illness (SMI) face one of the greatest health inequality gaps in England, with their life expectancy being 10–20 years lower than the general population. Laursen et al [1] identified that the rate of all-cause mortality in those with bipolar disorder was 1.77 times the general populations (95% CI 1.67-1.88) and in those with schizophrenia was 2.08 times greater (1.98-2.19). These findings were replicated in a longitudinal study of UK electronic primary care health record by Hayes et al [2], where it was reported that mortality rates of people with schizophrenia and bipolar disorder were around twice that of the general population. Of additional concern was that despite all-cause mortality in bipolar falling between 2000 to 2014 in line with the general populations, that this decline was slower in schizophrenia, resulting in an increase in the absolute mortality gap. Of note, the differences in mortality were not primarily from suicide but from other medical causes.

Despite the clear evidence of increased morbidity and mortality in this vulnerable group they often receive suboptimal levels of physical examination and medical monitoring in psychiatric settings as well as relatively low levels of medical (or preventative) care in medical settings [3]. There is evidence that addressing negative health behaviours has been more effective in the general population, for example, population-level smoking cessation programmes have had less impact on people with SMI1. There is a recognition that the disparity in morbidity and mortality is partly due to this group not being supported to use available health advice or to take up interventions that reduce the risk of preventable health conditions [4].

Indeed, there is evidence that people with schizophrenia are less likely than their healthy controls to report physical symptoms spontaneously [5], which can allow for early detection of warning signs.  Kisely et al’s [6]  linkage analysis of mental health records, cancer registrations and death records in Western Australia from 1988 to 2000, compared psychiatric patients with the general Western Australia population: whilst cancer incidence was lower in the psychiatric population in both males and females, the proportion of cancer with metastases at presentation was significantly higher in the psychiatric population (7.1%; 95% CI, 6.5%-7.8%) than in the general population (6.1%: 95% CI, 6.0%-6.2%). This highlights that this cohort in particular, may benefit from being included in national physical health preventative screening programmes to detect physical comorbidities in their early and potentially treatable stages.  Conversely however, there is evidence that cancer screening in patients with mental illnesses such as major depression and schizophrenia is suboptimal [7]. Martens et al [8] found that women with schizophrenia were less likely to have a cervical smear test compared to other women (58.8% vs 67.8% p<.0001). The situation is paralleled with breast cancer screening. A UK based study examined cross sectional data of breast screening records for 933 patients with psychiatric illness and over 440 000 women without mental health problems aged 50-64; they found that although patients’ attendance for screening was comparable, patients with a history of multiple detentions under the Mental Health Act were significantly less likely to attend, as were patients with a diagnosis of psychosis [9]. Similarly, a metanalysis by Mitchell et al [10] showed significantly reduced rates of mammography screening in women with mental illness (OR = 0.71, 95% CI 0.66–0.77), and particularly SMI (OR = 0.54, 95% CI 0.45–0.65).

National physical health screening programmes also include non-cancerous conditions. This is particularly relevant to the SMI population, with their increasing rates of diabetes, carrying the risk of retinopathy and long-term visual loss. Dixon et al [11] reported on the USA’s Schizophrenia Patient Outcomes Research Team (PORT) which interviewed 719 people with schizophrenia about their physical health between 1991 and 1996; it found a self- reported prevalence for life time diabetes of 14.9% and current diabetes of 10.8%, compared to the general populations’ reported prevalence rates of 1.2% in 18-44-year-olds and 6.3% in 45-64-year-olds. It is also worth noting that the PORT study was likely before the wide spread use of atypical antipsychotics.

It becomes apparent that deaths which could have been avoided by medical treatment in schizophrenia are more common than in the general population, and many of the excess deaths are potentially preventable by better medical treatment [12].  With this aim, health practitioners must ensure that everything is done to reduce disparities in health [2].

 

Aims

Glenhurst Lodge and Langford Centre are inpatient rehabilitation settings for males and females, over 18 years in age, with a primary diagnosis of severe mental illness with complex care needs, often affecting their functioning or presenting with risks. The Langford Centre also offers a low secure service for males and a challenging behaviour/personality disorder service for females. The residents therefore fall into the groups of patients that are recognised to be at higher risk of physical comorbidities as a result of SMI and associated factors. We set out to assess compliance of our resident in-patients within these two rehabilitation units, with national physical health screening programmes.   We also aimed to identify barriers to compliance with screening programmes, with the aim of informing strategies that could be implemented to enhance compliance. 

 

Method

The initial-audit was carried out on two male and two female wards within the rehabilitation settings of Glenhurst Lodge, Maidstone and Langford Centre, Bexhill. The audit proposal was approved by Bramley Health’s Medical Committee. We carried out a retrospective case-note audit of all residents in June/July 2018 (n=32) based on convenience sampling. Case notes were reviewed and data extracted regarding the following variables: age, gender and diagnosis of diabetes. This allowed the eligibility of individuals for various screening programmes to be evaluated. Admission assessments and annual physical health reviews were examined, these being the current tools used to capture screening information within the units. Additional information was sought as required from primary care and national screening programmes. The re-audit data was collected in December 2018.

 

Audit Standards

Current adult population screening programmes include screening for breast, cervical and bowel cancer, abdominal aortic aneurysm and diabetic retinopathy. These are accessible for residents who are registered with a general practice [13].  

Cervical cancer screening is available to women aged 25-49, whom are invited to attend a cervical smear every three years, and women aged 50-64 who are invited to attend a cervical smear every five years. Breast cancer screening is available to women aged 50 to 70, who are invited to attend mammogram every three years. Bowel cancer screening is available to both men and women aged 60 to 74, whom are invited to complete a home testing kit every two years. A new programme of ‘bowel scope screening’ is being rolled out throughout the UK, this being a one-off Flexible sigmoidoscopy for men and women age 55, however this was not available to all general practices at the time of the audit.  Abdominal aortic aneurysm screening is available for men aged over 65, whom are invited for a one-off abdominal ultrasound. Diabetic eye screening is available to both men and women identified as being diabetic, whom are invited for annual digital eye screening.  

Current uptake rates within the UK’s general population are 70.5% for breast screening, 59% for bowel screening and a coverage of 72% for cervical screening. Coverage rate for abdominal aneurysm screening is 80.9% and uptake rate for diabetic retinopathy screening is 82.2% [14] .

The compliance target for our residents eligible for national screening programmes was set at 100%. For the purpose of the audit, non-attendance at screening which was documented as being informed and capacitous was accepted as a valid exclusion. The new programme of ‘bowel scope screening’ was not included as a current standard as this was not universally available.

Involvement of residents who were non-compliant with an aspect of their screening (n=8) was sought with a questionnaire (Appendix 1) with the aim of identifying potential barriers to their accessing screening programmes. Barriers were broadly categorised as those related to knowledge, emotional and practical factors:

  • Knowledge based factors included not having read the information/invitation leading to; and a lack of awareness that screening is for asymptomatic individuals.
  • Emotional factors included not being able to face the test due to being embarrassed or fearful of pain; a negative experience of a previous test; feeling overwhelmed by worry about what the test might find; associating the screening with an invasion of personal space; and mistrust of the screening programmes.
  • Practical factors included the invite being sent to an incorrect address; or difficulty making an appointment.

The results of the baseline audit prompted us to review the current tools used to capture screening information: the admission assessment and annual physical health review. It was noted that the documents currently used to capture screening information did not identify all the current national screening programmes nor their eligibility criteria; did not capture the individual’s reason for declining screening; did not address issues regarding an individual’s capacity to make a decision to decline screening; and did not prompt discussion around commonly identified barriers that may support residents in making their own decisions regarding screening.  An amended screening assessment was incorporated into the admission and annual physical health review.

A re-audit was carried out of all resident in-patients on the same rehabilitation units, two male and two female wards in December 2018 (n=25) and the results were compared to the baseline audit. The re-audit used data from the newly designed admission assessment and annual physical health review which had been completed for all patients (n=25).

 

Results

All residents were registered with a general practitioner. In the pre-audit 50% (n=16) were eligible for some form of screening and this was comparable with 52% (n=13) in the re-audit.

In the initial-audit, 3 residents were eligible for breast cancer screening, of these 100% (n=3) were compliant. This met the compliance target set at 100% and was a 29.5% greater than uptake in the general population. This was comparable with the results of the re-audit, where again 3 residents were eligible, of which 100% (n=3) were compliant.

In the initial-audit, 11 residents were eligible for cervical cancer screening, of these 54.5% (n=6) were compliant. All 5 non-compliant residents had been offered screening but had declined to attend, however there did not appear to be any detailed documentation regarding their capacity or reasoning for declining. This did not meet the compliance target set at 100% and was 17.5% lower than uptake in the general population. Upon re-audit, 8 residents were eligible, of these compliances had improved with 75% (n=6) now being compliant: 3 had attended their screening appointments; 3 had documented informed and capacitous decisions not to attend for screening and thus were valid exclusions. However, 25% (n=2) did not have their screening details documented or any documented reasons for having declined screening, or their capacity to do so.

In the initial-audit, 3 residents were eligible for bowel cancer screening, of these 1 had undertaken screening; 1 had been offered screening but had declined with documented evidence that he lacked capacity and it would not be in his best interest in line with his palliative care plan (a valid exclusion); 1 had been offered screening but had declined, however there was no documentation regarding the reason for declining or their capacity to do so. Thus 66.7% (n=2) were compliant, this did not meet the compliance target set at 100%, but was 7.7% greater than uptake in the general population. Upon re-audit, 3 residents were eligible, compliance had improved with 100% (n=3) now being compliant: 2 had attended their screening appointments and 1 had a documented informed and capacitous decision not to attend for screening (a valid exclusion). This met the compliance target set at 100%.

In the initial-audit, 0 residents were eligible for abdominal aneurysm screening, thus further analysis was not possible for this population. Upon re-audit, 1 resident was eligible whom had attended screening and thus compliance was 100% (n=1).  This met the compliance target set at 100%.

In the initial-audit, 7 residents were eligible for diabetic eye screening, of these 3 had undertaken screening. Of the 4 residents who had not undergone screening:  1 had been offered screening but had declined with documented evidence that he lacked capacity and it would not be in his best interest in line with his palliative care plan (a valid exclusion); 1 was confirmed as being overdue for screening with the  screening programme; 1 had been offered screening but had declined without documentation regarding the reason for declining or their capacity to do so; 1 patient’s eligibility for screening was unclear with his  having  a diagnosis of ‘borderline diabetes’ treated with an oral hypoglycaemic (a formal diagnosis of diabetes being unconfirmed). Thus 57.1% (n=4) were compliant. This did not meet the compliance target set at 100% and was 25.1% lower than uptake in the general population. Upon re-audit, 6 residents were eligible, compliance had improved with 100% (n=6) now deemed to be compliant: 4 had attended their screening appointments; 1 was a new admission from a different locality whose diabetic eye appointment was being actively rearranged locally; 1 had been diagnosed as diabetic within the last fortnight and thus the screening referral was currently being made by primary care.  This met the compliance target set at 100%.

 

Figure 1

Audit population at baseline- % compliance with national screening programmes

Gen population- % uptake of national screening programmes

Figure 2

Audit population at baseline- % compliance with national screening programmes

Re-audit population- % compliance with national screening programmes

The response rate to the questionnaire regarding barriers to screening was 75% (n=6). Of responders 100% (n= 6) stated their physical health was important to them. 100% (n=6) were aware that screening is for everyone even those without any symptoms, and 83.3% (n=5) read the screening invite that was sent to them, with 66.7% (n=4) reading the information leaflet enclosed. Barriers to uptake included feeling that screening was an invasion of personal space in 66.7% (n=4); not trusting screening programmes with health information in 50% (n=3); concerns that screening may hurt in 50% (n=3); intending to go but not getting around to it in 50% (n=3); previous negative experiences of screening in 33.3% (n=2); and worrying what might be found in 33.3% (n=2). Many of these barriers were considered in the context of significant levels of past trauma and anxiety in the SMI population. Less frequent barriers included fear of being embarrassed 16.7% (n=1); and practical considerations such as having difficulty making a screening appointment 16.7% (n=1) or the screening invite being sent to the incorrect address 0% (n=0).

 

Discussion

Our results indicate that people living with SMI consider their physical health important, however despite this their use of national screening programmes is suboptimal in areas of cervical screening (54.5%  compliant at baseline); diabetic eye screening (57.1% compliant at baseline); and bowel screening (66.7% compliant at baseline). Uptake of breast screening was good with 100% compliant at baseline; no baseline data was available regarding aneurysm screening as no residents were eligible.

Our results indicate that emotional barriers in particular, impacted upon uptake of screening. Invasion of personal space was an issue in 66.7%; mistrust of screening programmes and concerns that screening may hurt in 50%; previous negative experiences and worrying what might be found in 33.3%. Such barriers could be understood in the context of significant levels of past trauma and anxiety in the SMI population and bring to mind the sensitivity of some patients to the gender of the practitioner carrying out the screening procedure as identified by Cormac et al [15]. It is considered that persons with SMI may have impaired planning and executive functions which could be relevant in the 50% of questionnaire respondents whom identified that they intending to attend screening, but did not ‘get around to it’.

A Cochrane review by Tosh et al [16], concluded that general physical health advice could lead to people with serious mental illness accessing more health services which, in turn, could result in longer term benefits such as reduced mortality or morbidity. This is reflected in our findings, which indicate that patients with SMI can be supported to access screening, with improved rates of compliance following implemented interventions. The interventions made it clear which screening programmes persons were eligible for; supported people to consider and overcome individual barriers to screening; and addressed issues relating to capacity to consent should this arise. Following the interventions, cervical screening compliance increased from 54.5% to 75%; diabetic eye screening from 57.1% to 100%; and bowel screening from 66.7% to 100%. Uptake of breast screening remained compliant at 100% following the intervention, and aneurysm screening also met the compliance target of 100%.

Psychiatrists have a duty of care to support patients in optimising their patients’ health alongside primary care colleagues. It has been recognised that the orientation of primary care is reactive and does not fit well with patients who may be reluctant, or unable, to seek help [17]. However, few psychiatrists have up-to-date skills in primary care or health promotion [15].

A longer term, inpatient admission such as within a rehabilitation setting, is an ideal opportunity to ensure that patients are up-to-date with preventative health strategies such as national screening programmes; thus optimising both their longer term physical and mental health recovery. Within such settings, collaborative treatment within trusting therapeutic relationships can support patients to consider and overcome barriers to screening. Mental health settings should provide a supportive framework that allows an assessment of patients’ eligibility for screening programmes; provision of appropriate screening information; consideration of issues relating to capacity to consent; and support to consider and overcome personal barriers to screening. Such a framework could empower those living with SMI to experience greater levels of autonomy in making informed decisions regarding their health, and lead to lower levels of morbidity and mortality.

 

References

[1] Laursen TM. Life expectancy among persons with schizophrenia or bipolar affective disorder. Scizophr res 2011 Sep; 131(1-3):101-4

[2] Hayes JF, Marston L, Walters K, King MB, Osborn DP. Mortality gap for people with bipolar disorder and Schizophrenia: UK-based cohort study 2000-2014. Br J Psychiatry 2017 Sep; 211(3):175-81

[3] Mitchell A, Delaffon V, Lord O. Let’s get physical: improving the medical care of people with severe mental illness. Adv Psychiatr Treat 2012 May; 18(3):216-25

[4] Improving physical healthcare for people living with serious mental illness in primary care. NHS England 2018 Feb.

[5] Jeste DV, Gladsjo JA, Lindamer LA, Lacro JP. Medical comorbidity in schizophrenia. Schizophrenia Bull 1996; 22(3):413-30

[6] Kisely S, Crowe E, Lawrence D. Cancer-Related Mortality in People with Mental Illness. JAMA Psychiatry 2013; 70(2):209-17

[7] Aggarwal A, Pandurangi A, Smith W. Disparities in Breast and Cervical Cancer Screening in Women with Mental Illness: A Systemic Literature Review. Am J Prev Med 2013 Apr; 44(4):392-98

[8] Martens PJ, Chochinov HM, Prior HJ, Fransoo R, Burland E. Are cervical cancer screening rates different for women with Schizophrenia? A Manitoba population-based study. J Schres 2009 Aug;113(1):101-06

[9] Werneke U, Horn O, Maryon-Davis A, Wessely S, Donnan S, McPherson K. Uptake of screening for breast cancer in patients with mental health problems. J Epidemiol Community Health 2006; 60:600-05

[10] Mitchell AJ, Pereira IE,  Yadegarfar M, Pepereke S. Breast cancer screening in women with mental illness: comparative meta-analysis of mammography uptake. Br J Psychiatry 2014 Dec; 205(6):428-35

[11] Dixon L, Weiden P, Delahanty J, Goldberg R, Postrado L, Lucksted A et al. Prevalence and correlates of Diabetes in National Schizophrenia Samples. Schizophr Bull 2000; 26 (4): 903-12

[12] Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000 Sep; 177(3): 212-17

[13] UK National Screening Committee. legacyscreening.phe.org.uk/screening-recommendations.php

[14] NHS Screening Programmes in England -1 April 2016 to 31 March 2017. Public Health England. assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/661677/NHS_Screening_Programmes_in_England_2016_to_2017_web_version_final.pdf

[15] Cormac I, Martin D, Ferriter M. Improving the physical health of long stay psychiatric in-patients. Adv Psychiatr Treat 2004 Mar; 10(2): 107-15.

[16] Tosh G, Clifton AV, Xia J, White MM. General physical health advice for people with serious mental illness.  Cochrane Database Syst Rev 2014; ArtNo:CD008567(3)

[17] Phelan M, Stradins L, Morrison S. Physical health of people with severe mental illness can be improved if primary care and mental health professionals pay attention to it.  BMJ 2001 Feb; 322: 443-4 

 

Appendix 1 Screening questionnaire

Your physical health is important to you? Y/N

What you know about screening

  • When you are sent an invite for screening, do you read the invitation and information leaflet? Y/N
  • Are you aware that screening is for everyone, even people without symptoms? Y/N

How you feel about screening

  • Have you found it difficult to face up to screening because of being embarrassed? Y/N
  • Have you found it difficult to face up to screening because it might hurt? Y/N
  • Have you found it difficult to face up to screening because of a previous negative experience of a screening test? Y/N
  • Have you found it difficult to face up to screening because you worry about what might be found? Y/N
  • Have you found it difficult to face up to screening because it seems an invasion of your personal space? Y/N
  • Are you worried about trusting screening programmes with information about your health? Y/N

How you arrange screening

  • Is your screening invite sent to the correct address? Y/N
  • When you were sent an invite for screening, did you intend to go but just did not get round to it? Y/N
  • Have you had difficulty making a screening appointment? Y/N

 

About the authors

Rhian Bradley is currently a ST4 in general adult psychiatry, and Vijay Delaffon is a Consultant Psychiatrist working within Kent and Medway NHS Partnership Trust, both previously worked at Bramley Health.